Posts Tagged ‘medicare’

Medicare Part D – Policy costs and the donut hole

Friday, February 10th, 2012

To continue with our discussion of Medicare Part D prescription drug coverage, this article will discuss the costs of Part D and the coverage gap, also called the “donut hole.”

Policy costs


There are many factors that will influence the cost of your Part D coverage. They will vary depending on the types of drugs you use and whether or not your plan covers them. The type of plan you choose is another variable, as is the pharmacy you use and whether or not it is part of a network. There will be a monthly premium that you pay, in addition to the premium that you pay for your Medicare Part B. If you belong to a Medicare Advantage plan that includes prescription drug coverage, then your prescription drug plan costs will be added to the plan’s monthly premium.

Deductibles and copayments:

Most prescription drug policies require the insured to pay an annual deductible of up to $310. After you have paid the deductible, you are then required to pay a copayment on your prescriptions until the combined amount paid by you and the insurance plan comes to $2840. Once you have reached a total of $2840, you are then in what is called the coverage gap, or the donut hole. This is a temporary limit on what the drug plan will cover for your prescription drugs.

Coverage gap or donut hole

As stated previously, you enter the coverage gap or donut hole once you and your insurance company together have spent over $2840 in one calendar year. Once you are in the donut hole, you are then responsible for the total cost of your prescription drugs until your drug coverage kicks in again. In 2011, covered individuals paid 50% of the cost of name-brand prescription drugs and 93% of the cost of generic drugs while in the coverage gap. These costs will drop in subsequent years until by 2020 participants will be paying no more that 25% of the cost of their prescriptions while in the gap.

You are able to get out of the gap when the total amount spent reaches $4550 (in 2011). This includes the pre-gap payments of $2840, plus $1710 paid on prescription drugs while in the gap. When calculating the $1710 spent while in the gap, the actual cost of the name-brand drugs is counted toward the total, not just the 50% discount. Once an individual has reached the $4550 limit, then catastrophic drug coverage kicks in.

Catastrophic drug coverage

With catastrophic drug coverage, the prescription drug plan will cover 95% of the remaining drug costs for the rest of the calendar year. Then it begins all over again.

Some Part D plans do offer additional gap coverage that will cover generic drugs while in the gap, but these plans will have a higher monthly premium. Qualified individuals can also apply for Extra Help. This is a program for people with limited income and resources provided by Medicare and Social Security. You would apply for Extra Help at your local Social Security office.


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Part C – Medicare Advantage Plans – Reasons to choose one, enrolling, and leaving Medicare Advantage plans

Friday, January 20th, 2012

Reasons to choose an Advantage Plan

Qualified Medicare participants choose to participate in an Advantage Plan for many reasons. As we have already mentioned, Medicare Advantage offers additional coverage that original Medicare doesn’t have, such as vision, hearing, dental, and/or health and wellness programs. Most also include prescription drug coverage. Additionally, Medical Advantage plans also provide coverage for emergency and urgent care. Keep in mind that these additional coverages often come with additional monthly premiums that the participants are responsible for. In addition to your Part B premium, Medical Advantage participants usually pay a copayment or coinsurance for covered services, and as well as a monthly premium.

Many Medicare beneficiaries have a wider array of health plan options from which they can choose, when they enroll in a Medicare Advantage HMO or PPO. These plans typically offer Medicare recipients benefits at a lower cost because enrollees can only get covered health care through the plan’s network of providers. This restriction allows the insurance company to “manage” the costs. The result is that participants are allowed to obtain the best coverage they can get at a cost they can afford.

Enrolling in a Medicare Advantage Plan

Participants who enroll in a Medicare Advantage program will continue to receive all Original Medicare covered services. Additionally, you may be able to lower your out-of-pocket costs and also receive extra benefits and services that are not offered by Original Medicare. Whether or not you save money, as well as the number and type of extra benefits and services you receive is dependent upon which Medicare Advantage plan you sign up for.

Note: Private insurance companies that offer Medicare Advantage plans have the freedom to change the plans’ benefits on an annual basis. They can also decide whether or not they choose to continue participating in Medicare; they can join or leave the Medicare program at any time.

Qualified Medicare recipients must be entitled to Medicare Part A and be enrolled in Part B in order to enroll in a Medicare Advantage plan. Most recipients do not realize that not all plans are available in all areas. You can only enroll in a plan that is available in your area. Qualified individuals can enroll in a Medicare Advantage plan when they first become eligible, if they are new to Medicare.

Your initial eligibility time frame is a seven-month period called the Initial Enrollment Period (IEP). It begins three months before your birthday month (if your birthday falls on the first of the month, your birthday month is the previous month), includes your birthday month, and the three months after your birthday month.

Thereafter, if you are enrolled in a Medicare Advantage plan, you can only make changes to the plan or adopt a different plan during scheduled times called enrollment periods.

 One enrollment period is called the Annual Coordinated Election Period (AEP) and occurs from October 15 to December 7 of each year. During this time period, anyone with Medicare can make changes to their coverage such as selecting a new Medicare health plan and/or a Medicare prescription drug plan. Any changes made during this time will take effect July 1. For more information, go to or call Medicare at 1-800-MEDICARE (1-800-633-4227).

Leaving a Medical Advantage Plan

As of January 1, 2011, there is no longer an Open Enrollment Period (OEP). Instead, there is now the Medicare Advantage Disenrollment Period (MADP). The MADP runs from January 1 through February 14. Participants can disenroll from their Medicare Advantage plan and return to Original Medicare during the MADP. By disenrolling from the Medicare Advantage plan, individuals may also enroll in a Part D Prescription Drug plan, whether or not their Medicare Advantage plan included prescription drug coverage. They are also then eligible to apply for a Medicare Supplement (Medigap) policy.

Participants may also qualify to leave their Medicare Advantage plan if they become eligible for a Special Election Period (SEP).

 Some examples of special election period qualifications are:

  • That you are in a MA plan that is leaving Medicare.
  • Your Medigap insurance company goes bankrupt and you lose your coverage.
  • You are in a MA plan and you move out of the plan’s service area.
  • You live in a Long Term Care Facility (e.g., a nursing home or rehabilitation hospital).
  • You are losing Employer or Union Group Health Coverage.



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Medicare Part A Coverage Continued

Friday, December 23rd, 2011

Skilled nursing facility care, home health care, hospice & psychiatric hospitalization

In addition to inpatient hospitalization, Medicare Part A also provides medical coverage for skilled nursing facility care, home health care, and hospice & psychiatric hospitalization.

Skilled Nursing Facility Care

Medicare defines a skilled nursing facility as, “A nursing facility with the staff and equipment to give skilled nursing care and, in most cases, skilled rehabilitative services and other related health services.”

In order to be covered by Medicare Part A, stays at nursing homes or skilled nursing facilities must be related to the diagnosis made during a hospital stay. For instance, if your hospital stay was for a stroke, then a nursing home or skilled nursing facility stay for rehabilitation would be covered. A nursing home or skilled nursing facility stay coverage includes charges for a semi-private room, meals, and rehabilitative and skilled nursing services and care.

The coverage is limited to a maximum of 100 days in a benefit period. A benefit period is defined by Medicare as beginning the day you go into a hospital or skilled nursing facility, and ending when you haven’t received any hospital or skilled nursing care for 60 days. If you go back into a hospital or skilled nursing care facility after one benefit period has ended, then a new benefit period begins. You must pay the deductible for each benefit period, and there is no limit to the number of benefit periods. The first 20 days of a benefit period are paid in full (after the deductible), and the remaining 80 days will require a co-payment. As of 2011, this is $141.50 per day. Medicare Part A will not cover long-term care, non-skilled care, daily living, or custodial activities.

Home Health Services

Home health services are described by Medicare as health care services and supplies that a doctor decides you may receive in your home, under a plan of care established by your doctor. Medicare only covers home health care on a limited basis, as ordered by your doctor. It includes limited reasonable and medically necessary part-time care and services, such as skilled nursing care, physical or occupational therapy, home health aide service, speech language pathology, and medical social services. It also includes certain home-use medical equipment (wheelchairs, hospital beds, walkers, oxygen), and other medical supplies.

Hospice Care

Hospice care is for the terminally ill who have six months or less to live. Hospice care involves a team-oriented approach that addresses the medical, physical, social, emotional, and spiritual needs of the patient. Hospice also provides support to the patient’s family or caregiver as well. Coverage includes drugs for relief of pain and to control symptoms, medical, nursing, and support services, grief counseling, and other services. Care is to be provided by a nearby, Medicare-approved hospice caregiver who will visit you at your home. Medicare also provides additional care for a hospice patient in an approved facility, so that the usual caregiver can get a respite. These respite care stays are covered for up to 5 days.

Medicare Part D

Tuesday, June 1st, 2010

Prescription drugs are rather expensive, and this is something that you should keep in mind whenever choosing the various insurance policies that you have. If you’re already covered under Medicare A or B, you also qualify for prescription drug coverage under Medicare part D. You may also be able to get Medicare coverage for your drugs if you are under one of the Medicare advantage programs, but these typically come with their own drug coverage plans in place. Here are some things to consider whenever choosing Medicare part D.

One thing for you to consider is the time in which you apply for Medicare part D. For the most part, you’re going to be able to apply for this prescription drug coverage for the three months before you become eligible for Medicare and the three months after you become eligible. If you miss this window, you may be charged a late enrollment fee and you will not be eligible to apply for Medicare part D until November 15th. You will also have a limited amount of time that you will be able to enroll during this period, and if you miss it, you will have to wait until November of the following year.

Whenever you sign up for Medicare part D, you’re going to be responsible for paying a monthly premium as well as some copayments and perhaps an annual deductible. If you are having a difficult time covering these costs, and you qualify financially, you may be able to receive further assistance that will cover these costs for you. This is an excellent way to make sure that you get the prescription medication that you need and are not denied the medication because you are not able to afford it. If you think that you may qualify for one of these plans and would like to take advantage of it, contact Medicare to fill out the proper paperwork.

As we get older, our needs for prescription medications tend to increase. Even if you do not have a need for Medicare part D at this time, it may be a good idea for you to get it so that you’re going to be covered in the future. Unexpected prescription medications can cost quite a bit, particularly whenever they are administered by the hospital. If you have a Medicare drug policy in place, you will be covered for these unexpected expenses as well.

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